Southern Cross Medical Library

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Achilles tendon rupture (tear)

An Achilles tendon rupture injury is when the tendon fibres tear, causing pain and loss of function. A rupture can be either partial or complete. Treatment may involve surgery.

Achilles tendon rupture is common in weekend athletes trying to play/train too hard and is less common in well-trained professional athletes. The injury is more common in men than in women and the frequency of rupture increases over the age of 30 years.

Signs and symptoms

When the Achilles tendon ruptures a popping or snapping sound may be heard. The person may feel that they have been hit or kicked in the back of the lower leg. This is quickly followed by the sudden onset of sharp pain in the tendon and a loss of strength and function. If a complete rupture has occurred it may not be possible to lift the heel off the ground or point the toes.
Often the degree of pain experienced, or lack of it, can be inversely proportional to the extent of the injury, ie: a partial rupture may in fact be more painful than a complete rupture.

Causes

The Achilles tendon is a strong band of fibrous connective tissue that attaches the calf muscle to the heel bone. When the muscle contracts, the tendon pulls the heel causing foot movement.

The Achilles tendon ruptures because the load applied to it is greater than the tendon's ability to withstand that load. This usually occurs as a result of a sudden, quick movement where there is a forceful stretch of the tendon or a contraction of the muscles, eg: jumping, sprinting, or pushing off to serve in tennis. This occurs most often in sports that require a lot of stopping and starting (acceleration-deceleration sports) such as tennis, basketball, netball, and squash.

The Achilles tendon is on average 15cm in length. Most ruptures occur 3-6cm above where the tendon inserts into the heel bone. This is the narrowest portion of the Achilles tendon.

Achilles tendon rupture is most common when the muscles and tendon have not been adequately stretched and warmed up prior to exercise, or when the muscles are fatigued. The Achilles tendon has a poor blood supply, which makes it susceptible to injury and slow to heal after injury. During exercise the amount of blood able to travel to the tendon is decreased, further increasing the risk of rupture.

Most experts agree that there are no warning signs of an impending rupture. However, frequent episodes of Achilles tendonitis (tendon inflammation) can weaken the tendon and make it more susceptible to rupture.

Other factors that may increase the risk of Achilles tendon rupture include:

Diagnosis

If an Achilles tendon rupture is suspected, it is important to consult a doctor straight away so that an accurate diagnosis can be made and appropriate treatment recommended. Until a doctor can be consulted it is important to let the foot hang down with the toes pointed to the ground. This prevents the ends of the ruptured tendon pulling any farther apart.

The doctor will take a full medical history, including any previous Achilles tendon injuries and what activity was being undertaken at the time the present injury occurred.

The doctor will also conduct a physical examination and will check for swelling, tenderness, and range of movement in the lower leg and foot. A noticeable gap may be able to be felt in the tendon at the site of a complete rupture. This is most obvious just after the rupture has occurred and swelling will eventually make this gap difficult to feel.

One test commonly used to confirm an Achilles tendon rupture is the Thomson test. For this test, the patient lies face down on an examination table. The doctor then squeezes the calf muscles; an action that would normally cause the foot to point like a ballerina (plantar flexion). When a partial rupture has occurred the foot's ability to point may be decreased. When a complete rupture has occurred, the foot may not point at all.

Ultrasound scanning and MRI (magnetic resonance imaging) of the Achilles tendon may also be recommended to help determine the extent of the rupture.

Treatment

Once a diagnosis of Achilles tendon rupture has been confirmed, a referral to an orthopaedic specialist for treatment will be recommended.

Treatment for an Achilles tendon rupture aims to facilitate the torn ends of the tendon healing back together again. Treatment may be non-surgical (conservative) or surgical. Factors such as the site and extent of the rupture, the time since the rupture occurred and the preferences of the specialist and patient will be considered when deciding which treatment will be undertaken. Some cases of rupture that have not responded well to non-surgical treatment may require surgery at a later stage.

Non-surgical treatment
The doctor will immobilise the ankle in a cast or a special hinged splint (known as a “moon boot”) with the foot in a toes-pointed position, which brings the two ends of the torn tendon together allowing it to heal. The cast or splint will stay in place for 6-8 weeks. The cast will be checked and may be changed during this time.

Surgical treatment
The surgeon makes an incision in the skin over the ruptured portion of the tendon and joins the ends of the tendon together with strong sutures (stitches), allowing the tendon to closely approximate its previous length. The skin is then closed with sutures and the foot is immobilised in a cast or splint, again in the toes-pointed position. Seven to ten days after surgery, the cast or splint is removed in order for the sutures in the skin to be removed. Another cast or splint will be applied and will stay in place a further 5-7 weeks.

The use of non-surgical versus surgical treatment for Achilles tendon rupture continues to be debated. Many research studies have been conducted as to the effectiveness of each treatment. Surgical treatment has in the past been the most preferred form of treatment for Achilles tendon rupture and the most commonly used in cases of complete rupture. Recent research, however, indicates that surgical treatment does not necessarily produce a more effective outcome than non-surgical treatment.

Both types of treatment have advantages and disadvantages. For example, the likelihood of re-rupture may be lower with surgical treatment while non-surgical treatment avoids the risks associated with surgical treatment, which include wound infection, nerve injury, and risks associated with the use of a general anaesthetic. It is important therefore to discuss the advantages and disadvantages of each treatment option with the specialist and to receive a clear explanation as to why a particular treatment has been recommended.

Recovery

While the cast or splint is in place it is important to regularly elevate and rest the foot. This will help to reduce swelling and promote healing. Crutches will need to be used and weight-bearing on the foot will be restricted.

After removal of the cast or splint an individual rehabilitation plan, involving physiotherapy and specific exercises, will be commenced. The aim of rehabilitation is to restore the strength of the Achilles tendon and calf muscles and the range of motion of the ankle. It may be recommended that flat shoes are avoided and/or a heel raise is used in footwear. This helps to reduce the load put onto the Achilles tendon.

Physiotherapy may need to be continued for several weeks or months during which time activity is gradually increased. It may be six months to a year before the Achilles tendon is back to full strength. During this time, it is very important to follow the instructions of the specialist and physiotherapist in order to prevent any further injury to the Achilles tendon.

Recent research suggests that earlier and more intensive rehabilitation after surgery results in higher patient satisfaction and improved physical function without an increase in the risk of re-rupture.

Prevention

The following can significantly reduce the risk of Achilles tendon rupture:

Adequate stretching and warming up prior to exercising

If playing a seasonal sport, undertake preparatory exercises to build strength and endurance before the sporting season commences

Maintain a healthy body weight. This will reduce the load on the tendon and muscles

Use footwear appropriate for the sport or exercise being undertaken

Exercise within fitness limits and follow a sensible exercise programme

Increase exercise gradually and avoid unfamiliar strenuous exercise

Gradual “warm down” after exercising

Calf muscle stretching and strengthening exercises, which will allow the Achilles tendon to absorb greater forces and prevent injury.